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Treatments for common inflammatory skin disorders
2. Have a working knowledge of the treatments available for common inflammatory skin disorders including: Psoriasis, Eczema and Lichen Planus 'Psoriasis' Topical therapy As a first and base line therapy, usage of emollients, in line with BNF and childrens' BNF guidelines, should be recommended. Offer up to 4 weeks' initial therapy with a potent corticosteroid plus a vitamin D analogue (e.g. calcipotriol) to adults with trunk or limb psoriasis outbreak. NB: corticosteroids are not generally useful for long-term therapy. Tazarotene is a retinoid which has a similar efficacy to Vitamin D analogues. Coal tar has anti-inflammatory properties which are useful in chronic plaque psoriasis, however, few patients tolerate the smell and mess. Dithranol is effective for chronic plaque psoriasis. It should be applied to chronic extensor plaques only, and is not suitable for use in the flexures or on the face. Phototherapy Phototherapy with UVB light 2-3 times per week should be offered to those with plaque or guttate psoriasis which cannot be controlled by topical therapy alone. Photo therapy with UVA (PUVA) and a sensitising agent such as psoralen can be carried out in specialist centres under supervision of a dermatologist. It is suitable for most types of psoriasis, especially localised palmoplantar pustular psoriasis. Systemic therapy Systemic therapy should only be offered to those with disease that is severely impacting on their physical or psychosocial wellbeing, who have failed to respond to other treatment. Methotrexate (MTX) may be offered as a first-line systemic therapy. Ciclosporin may be offered as a first-line therapy in men or women trying to conceive. Acitretin may be used where ciclosporin and MTX have failed. Systemic Biological Therapy Biologic agents such as adalimumab may be indicated for treatment of psoriasis, but should only be initiated by an expert. Examples of such agents include etanercept, infliximab and adalimumab, and ustekinumab. 'Eczema' Lifestyle modification Avoidance of patient triggers, e.g. soaps, certain washing powders and cloth types, should be recommended. Topical therapy As a first and base line therapy, usage of emollients, in line with BNF and childrens' BNF guidelines, should be recommended. Treatment of mild flare-ups with topical corticosteroid cream. Strength of cream prescribed should be dependent on severity and location of outbreak, as well as other patient factors such as age. Bandages containing ichthammol paste may reduce pruritis. Antibiotic preparations may be used to treat infected eczema. Topical immunosuppressants, such as tacrolimus, may be prescribed by a dermatologist in refractory cases. Phototherapy Phototherapy may be recommended in cases of severe and refractory eczema, however, this should only be prescribed by a specialist. Oral therapy Azathioprine, methotrexate, ciclosporin and mycophenolate may be used short-term to attempt to control severe cases of eczema. However, they should not be prescribed long term due to their side effects. Antihistamines such as chloramphenamine and hydroxyzine may also be prescribed. Although they have no effect on the inflammation caused by the eczema, they may help sufferers to sleep at night. Pimecrolimus is an immunomodulator licensed for use in mild to moderate eczema. Tacrolimus is from the same class, but is licensed for moderate to severe eczema. These drugs should only be used in eczema which is unresponsive to maximal corticosteroid therapy. 'Lichen Planus' Mild cases Mild cases of lichen planus require no pharmacotherapy, only advice and reassurance. Moderate cases Potent steroid creams may be used on spots which are red or purple coloured and itchy. Patents should be advised not to use the steroid cream on the brown or grey spots, as it has no effect on them and will increase risk of side effects such as skin thinning. Severe cases Severe cases may be treated with oral steroids, ciclosporin, or acitretin. This should be initiated by a specialist only. Phototherapy Ultraviolet light therapy may help in cases of widespread lichen planus.